COVID-19 Questionnaire

Our offices are open for programs, groups, and mentorship. Our staff is also taking some meetings in person. Our virtual offerings are also still available, so if you are unwell, or if you do not feel comfortable entering our office space, please contact us to find an online option.

If you are planning to come into the Sagesse office, please complete the following form before each visit. Please be sure to identify your reason for visiting the office (i.e. participant/client, volunteer, etc.) so the form is sent to the correct department.


                

                        PLEASE COMPLETE THIS REQUIRED QUESTIONNAIRE TO DETERMINE IF YOU  SHOULD BE ACCESSING SAGESSE TODAY
If you answer YES to any of questions 1 through 7, you may not be allowed to attend or participate in the activity or program.

As the COVID-19 pandemic continues to evolve, this screening tool will be updated as required.
Please identify yourself:*
  1. Do you have/have you had any of the following symptoms in the  last 10 days?:  
Fever (greater than 38 degrees)*
			
				
				Yes
			
			
				
				No
			
Cough*
			
				
				Yes
			
			
				
				No
			
Shortness of breath/breathing difficulties*
			
				
				Yes
			
			
				
				No
			
Other symptoms such as muscle aches, fatigue, headache, sore throat, runny nose, diarrhea *Note symptoms in children may be non-specific – e.g. lethargy, poor feeding*
			
				
				Yes
			
			
				
				No
			
2. Have you travelled outside of Canada in the last 14 days?*
			
				
				Yes
			
			
				
				No
			
3. In the last 14 days, have you had close contact (face-to-face contact within 2 metres/6 feet) with someone who is ill with any of the symptoms outlined above?*
			
				
				Yes
			
			
				
				No
			
4. Have you been in contact with anyone who has recently travelled outside of Canada in the last 14 days?*
			
				
				Yes
			
			
				
				No
			
5. In the last 14 days, have you been in contact with someone that is being investigated or confirmed to be a case of COVID-19?*
			
				
				Yes
			
			
				
				No
			
6. Have you had laboratory exposure while working with specimens known to contain COVID-19?*
			
				
				Yes
			
			
				
				No
			
7. Have you had received a positive COVID-19 result in the last 14 days?*
			
				
				Yes
			
			
				
				No
			
8. Have you received the full series of a vaccine, or a combination of vaccines, accepted by the Government of Canada (Pfizer, Moderna, AstraZeneca, Janssen/Johnson & Johnson), with your last dose being at least 14 days before your onsite visit? Please note, while vaccinations are currently not required for people visiting our office, if you do not answer yes, Sagesse staff will contact you to discuss virtual meeting options if they have not already done so.
			
				
				Yes
			
			
				
				No
			
			
				
				Rather not say
			
If you answered "yes" to any of questions 1 through 7, you will be asked not to access Sagesse in-person office at this time.  We encourage you to access us instead via virtual options.

If you have answered “No” to questions 1 through 7, please read and sign the COVID-19 In-Person Support Informed Consent before accessing Sagesse.
 COVID-19 Risks 

I understand that the novel coronavirus causes the disease known as COVID-19. I understand that the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. 

I understand that by entering Sagesse and being exposed to different environment(s) and others, I may have an elevated risk of contracting COVID-19. 

I understand that accessing in-person support through Sagesse while using recommended precautions determined by Alberta Health Services (i.e. hand washing, PPE (personal protective equipment), and maintaining 2-meter distance from others) does not eliminate all risk for contracting COVID-19.

I understand that information and safety precautions surrounding COVID-19 may change at any time therefore impacting policies and procedures to in-person support. 

I understand that if I answered “No” to all COVID-19 assessment questions but I am presenting with any symptoms (i.e. Continuous cough, sneeze or others) during in-person support that I will be asked to leave and return only when symptoms are gone and I have a confirmed negative COVID-19 test result.  

Summary 

I confirm that by signing this form I do not have any presenting symptoms of COVID-19 and have not received a positive COVID-19 result in the last 14 days or been in close to contact with anyone who received a positive COVID-19 result in the last 14 days. 

I confirm that by signing this form that I understand the risks associated and have voluntarily decided and consent to receive in-person support through Sagesse.

I confirm that by signing this form and/or checking off this box I consent and will adhere to all Sagesse policies and procedures regarding in-person support to the best of my ability, including (but not limited to):

Temperature check before entering Sagesse office (Sagesse location specific) 
Wearing a Sagesse provided mask and/or face shield at all times when physical distancing is not guaranteed 
Hand washing and/or hand sanitizing upon entering Sagesse and each time I leave and return to Sagesse spaces (Sagesse location specific) 


 

By checking this box, I confirm that I have read the COVID-19 risks above and agree to the terms of this agreement.*
								
								I confirm.
							
Full name:* 
Email*
                            
                        
Phone number*

PLEASE COMPLETE THIS REQUIRED QUESTIONNAIRE TO DETERMINE IF YOU SHOULD BE ACCESSING SAGESSE TODAY

Be empowered to heal, learn and grow.